Tag: Obstetrics & Gynecology

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Case 80: Ovarian Cyst

Hanna Richkind, Elaine Yu

A 37-year-old woman with a past medical history of anxiety, insomnia, chronic low back pain, and intermittent lower abdominal pain presented to the Emergency Department with several days of worsening lower abdominal and back pain. Her symptoms acutely worsened after eating a meal and were accompanied by nausea, vomiting, and diarrhea. Although the vomiting and diarrhea subsequently resolved, she continued to experience lower abdominal discomfort with pain radiating to the left flank and mid-back. At times, the severity of the discomfort caused her to crouch for relief. She denied a history of prior abdominal surgery.

Vital Signs: T 98.1 °F (36.7 °C), BP 129/88, HR 82, RR 16, SpO2 98% on room air.

Physical Exam:

Const: Well-appearing

Head: Atraumatic

Eyes: Normal Conjunctiva

ENT: Normal external ears, nose, and Mouth

Neck: Full range of motion. No meningismus

Resp: Clear to auscultation bilaterally, normal work of breathing

Cardio: Regular rate and rhythm, no murmurs

Abd: Soft, non-tender, non-distended. No guarding or rigidity. Normal bowel sounds

Skin: No petechiae or rashes

Back: No midline or flank tenderness

Ext: No cyanosis or edema

Neuro: Awake and alert. Moves all extremities

Psych: Normal Mood and Affect

Labs: Creatinine 0.70, BUN 5, Lipase 26, WBC 10.4, Hgb 11.1, MCV 77.2, MCH 23.9. Urinalysis with trace protein and 3+ blood, no bacteria and few squamous epithelial cells.  Syphilis screen and human chorionic gonadotropin test were negative.

ED Course:

Labs largely unremarkable with no evidence of active infection. Upon further discussion, the patient reported that she had no difficulty with bowel movements or urination, but felt “heaviness” in her lower abdomen during and after urination.

Given the persistence of her abdominal discomfort and her report of lower abdominal pressure, point-of-care ultrasound (POCUS) was performed. Bedside transabdominal ultrasonography demonstrated a large complex cystic and solid pelvic mass measuring approximately 23 cm and extending toward the midline.

Figure 1: Transverse view of the right adnexa on pelvic ultrasound, demonstrating a complex cystic and solid mass.

Formal pelvic ultrasonography further localized the 23 cm mass to the right adnexa and confirmed a separate heterogenous 4cm left adnexal mass. Doppler imaging demonstrated preserved blood flow.

Figure 2: Transverse view of the left adnexa on pelvic ultrasound, demonstrating 4 centimeter heterogenous mass.
Figure 3: Clip showing relationship of 2 adjacent masses.

Discussion:

The differential diagnosis of lower abdominal and pelvic pain in a reproductive-age woman is broad and includes gastrointestinal, genitourinary, and gynecologic etiologies. Before POCUS, considerations in this patient included gastroenteritis, appendicitis, urinary tract infection, nephrolithiasis, ovarian cyst, uterine leiomyoma, ovarian torsion, ectopic pregnancy, and tubo-ovarian abscess.

The patient’s initial symptoms were compatible with an acute gastrointestinal illness. She developed nausea, vomiting, and diarrhea after eating a meal, and these symptoms subsequently resolved. However, persistence of lower abdominal and back pain after resolution of her gastrointestinal symptoms warranted reconsideration of the initial differential and evaluation for a structural cause of her symptoms (1). Furthermore, nausea and vomiting are nonspecific findings that may also occur in patients with symptomatic adnexal masses and ovarian torsion (2).

An important feature of this case was the relatively benign physical examination despite the presence of a 23 cm adnexal mass. The patient's abdomen remained soft, non-tender, and non-distended, and she had no appreciable flank or back tenderness. Although physical examination remains an important component of the evaluation of pelvic pain, examination alone may fail to identify significant adnexal pathology. Prior studies have demonstrated limited sensitivity of pelvic and bimanual examinations for the detection of adnexal masses (3). Accordingly, a reassuring examination should not preclude imaging when symptoms remain unexplained.

The patient’s description of lower abdominal “heaviness” during and after urination provided an additional clue suggesting a pelvic structural abnormality. Pelvic and adnexal masses may produce urinary pressure, frequency, urgency, or other lower urinary tract symptoms through mass effect on the bladder and surrounding structures (4). In this case, the urinary complaint prompted bedside imaging despite otherwise nonspecific symptoms and a reassuring abdominal examination.

Ovarian torsion remained an important diagnostic consideration given the presence of bilateral adnexal lesions. Adnexal masses increase the risk of torsion, particularly when greater than 5 cm in diameter, and mature cystic teratomas are recognized lead points for torsion (4). Although Doppler ultrasonography demonstrated preserved blood flow, normal arterial flow does not exclude ovarian torsion because of the dual blood supply to the ovary and the possibility of intermittent or incomplete torsion (2,4). Torsion was considered less likely in this patient given the subacute course, absence of persistent acute severe pain, improvement in nausea and vomiting, and overall clinical presentation.

Imaging plays a central role in the evaluation of acute pelvic pain. Transabdominal and transvaginal ultrasonography are generally the preferred initial imaging modalities when a gynecologic etiology is suspected. CT is commonly obtained when gastrointestinal or urinary pathology remains in the differential and may also identify previously unsuspected gynecologic abnormalities (6).

In this patient, POCUS rapidly redirected the diagnostic evaluation from common gastrointestinal and urinary causes of abdominal pain toward a previously unsuspected pelvic mass. The bedside examination identified significant pathology despite nonspecific symptoms, largely unremarkable laboratory testing, and a benign abdominal examination, prompting definitive cross-sectional and formal pelvic imaging.

Conclusion:

This case demonstrates the potential value of point-of-care ultrasound in patients with persistent abdominal or pelvic symptoms despite an initially reassuring examination and laboratory evaluation. A subtle complaint of urinary pressure prompted bedside ultrasonography that rapidly identified a large, previously unsuspected adnexal mass and redirected the diagnostic evaluation toward a gynecologic etiology. POCUS may therefore serve as a useful adjunct in the evaluation of undifferentiated abdominal and pelvic pain when the clinical presentation remains unexplained.

References:

  1. Bhavsar AK, Gelner EJ, Shorma T. Common Questions About the Evaluation of Acute Pelvic Pain. Am Fam Physician. 2016 Jan 1;93(1):41-8. PMID: 26760839.
  2. Adnexal Torsion in Adolescents: ACOG Committee Opinion No, 783 (2019). Obstetrics & Gynecology, 134(2), e56-e63. https://doi.org/10.1097/AOG.0000000000003373
  3. Biggs WS, Marks ST. Diagnosis and Management of Adnexal Masses. Am Fam Physician. 2016 Apr 15;93(8):676-81. PMID: 27175840.
  4. Wheeler V, Umstead B, Chadwick C. Adnexal Masses: Diagnosis and Management. Am Fam Physician. 2023 Dec;108(6):580-587. PMID: 38215419.
  5. Bonney R, Revels JW, Wang SS, Lussier R, Dey CB, Katz DS, Moshiri M. A comprehensive radiologic review of abdominal and pelvic torsions. Abdom Radiol (NY). 2021 Jun;46(6):2942-2960. doi: 10.1007/s00261-020-02868-x. Epub 2021 Jan 2. PMID: 33388807.
  6. Expert Panel on GYN and OB Imaging; Brook OR, Dadour JR, Robbins JB, Wasnik AP, Akin EA, Borloz MP, Dawkins AA, Feldman MK, Jones LP, Learman LA, Melamud K, Patel-Lippmann KK, Saphier CJ, Shampain K, Uyeda JW, VanBuren W, Kang SK. ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update. J Am Coll Radiol. 2024 Jun;21(6S):S3-S20. doi: 10.1016/j.jacr.2024.02.014. PMID: 38823952.
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Case 79: Uterine Rupture

Rachel Feiner MS4, Anthony J. Medak, MD

A 38-year-old female at 12 weeks gestation presented to the ED with acute-onset abdominal pain following intercourse with associated dizziness, nausea and diarrhea, which started the night before her presentation. She also described dizziness and presyncope on standing. She denies any vaginal bleeding, cramping, fever, or chills.

PMH: Asthma, Dog allergy, DeQuervain's tenosynovitis

OB Hx: G4P2022. Cesarean section, Low Transverse in 2020 for arrest of dilation. Cesarean section, inverse-T uterine incision in 2023 for transverse presentation.

Vital Signs: BP: 107/68, Pulse: 132, Temp: 97.8 F, Resp: 18, SpO2: 100% on RA

Abdominal Exam: Soft, non-tender, non-distended.

Labs: Na 134, K 4.2, Cl 100, Bicarb 19, Glucose 156, WBC 17.6k, Hgb 10.9. UPT positive.

A bedside ultrasound was performed.

Figure 1: Sagittal view of the cervix and posterior cul-de-sac on transvaginal ultrasound showing free fluid in the posterior cul-de-sac (green outline).
Figure 2: Coronal view of the right upper quadrant of the abdomen with free fluid in the hepatorenal space (green outline).
Figure 3: Sagittal and coronal views of the right adnexa on transvaginal ultrasound with a heterogeneous structure measuring 7.5 cm x 2.5 cm x 5.2 cm, most consistent with hematoma and clot (yellow calipers).
Figure 4: Sagittal view of the uterus and placenta on transvaginal ultrasound. Note the anterior location of the placenta (yellow calipers), and the relative heterogeneity of the inferior aspect of the placenta (green outline) compared to the superior aspect.

ED Course:

The patient had symptomatic improvement in the ED following administration of ondansetron, and IV fluids. OB/GYN was consulted given positive UPT and US findings concerning for adnexal mass with extensive free fluid in the abdomen.

On serial exams in the ED, the patient developed significant lower abdominal rebound tenderness. Repeat labs revealed a drop in hemoglobin from 10.9 to 8.8. The patient was taken to the OR for diagnostic laparoscopy by OB/GYN.

Hospital Admission Course:

The patient underwent diagnostic laparoscopy which revealed hemoperitoneum with approximately 2 L of blood and clot in the abdomen with continued active bleeding from the anterior lower uterine segment. The uterus was found to be ruptured at the site of the previous hysterotomies, and the placenta appeared to be growing through the uterine wall at the point of rupture.

Maternal-Fetal Medicine was consulted intraoperatively, given ongoing intra-abdominal hemorrhage. They confirmed the diagnosis of placenta accreta spectrum, in which the placenta had adhered and grown exophytically to the prior hysterotomy scar, resulting in uterine rupture. This also prompted concern for possible Cesarean scar ectopic pregnancy.

Massive transfusion protocol was initiated due to continued blood loss, and the patient received 6 units of pRBCs, 4 units of FFP, and 2 units of platelets. In the setting of such significant hemorrhage and the nonviable nature of the pregnancy, the patient's husband was counseled and agreed to proceed with an emergent life-saving hysterectomy. Estimated blood loss totaled 4.5 L, and the patient was admitted to the ICU postoperatively in stable condition.

The patient required 1 additional unit of pRBCs on postoperative day 2 due to a drop in hemoglobin from 9.7 to 7.3. CT scan at this time showed no evidence of ongoing active bleeding, and the patient was discharged home the following day.

Discussion:

This case demonstrates the utility of ultrasound in the risk stratification of a pregnant patient presenting with abdominal pain. POCUS was used in this case to rapidly identify that the patient had extensive free fluid in the abdomen. Interestingly, despite these provocative US findings, her triage BP and initial abdominal exam were unremarkable. While initially suspected to be simply a ruptured ovarian cyst, the finding of free fluid in the abdomen with the positive pregnancy test quickly led the clinicians to determine that she required emergent life-saving surgery.  

In cases of uterine rupture, US imaging is most commonly used to detect findings secondarily associated with uterine wall injury, such as free fluid in the peritoneum. However, direct signs may also be observed, especially later in gestation. These include fetal parts, umbilical cord, or the amniotic sac protruding through a defect in the uterine wall. This likely was not seen in this case due to the relatively early stage of the patient's pregnancy, and due to the large hematoma in the pelvis obstructing some views.

Thinning of the myometrium, as was noted with this patient, can also be used as a marker to assess for uterine dehiscence and risk of subsequent rupture. In this case, the exact myometrial thickness was not measured, but previous studies have indicated that a thickness <1.5 mm is a significant predictor of uterine dehiscence. Particularly in patients with prior Cesarean sections, such as in this case, US has been shown to be highly sensitive and specific in its ability to detect both uterine dehiscence and rupture.

Decreased retroplacental myometrial thickness on US is also a marker associated with placenta accreta spectrum. In addition, the inferior aspect of the patient's placenta was noted to be relatively heterogeneous on US compared to the superior aspect. This may reflect the presence of placental lacunae, which appear as hypoechoic irregularities within the placenta and are another marker for placenta accreta spectrum.

Pelvic US can be a valuable tool for rapidly assessing patients with obstetric and gynecologic complaints in the ED setting. In this case, abnormal POCUS imaging was utilized in conjunction with the patient's clinical course to distinguish between a relatively benign diagnosis, such as ovarian cyst rupture, and one which required immediate surgical intervention. When later reviewed by maternal-fetal medicine specialists, the POCUS images were used for intraoperative decision making, as the findings suggested possible involvement of the placenta with the prior Cesarean section scar. This case clearly demonstrates the integral role of POCUS in both the diagnosis and management of obstetric and gynecologic emergencies in the acute care setting.

References:

1. Gizzo S, Zambon A, Saccardi C, et al. Effective anatomical and functional status of the lower uterine segment at term: estimating the risk of uterine dehiscence by ultrasound. Fertility and Sterility. 2013;99(2):496-501.e2. doi:10.1016/j.fertnstert.2012.10.019

2. Aboughalia H, Basavalingu D, Revzin MV, Sienas LE, Katz DS, Moshiri M. Imaging evaluation of uterine perforation and rupture. Abdom Radiol. 2021;46(10):4946-4966. doi:10.1007/s00261-021-03171-z

3. Alalaf SK, Mansour TMM, Sileem SA, Shabila NP. Intrapartum ultrasound measurement of the lower uterine segment thickness in parturients with previous scar in labor: a cross-sectional study. BMC Pregnancy Childbirth. 2022;22(1):409. doi:10.1186/s12884-022-04747-3

4. Obstetric Care Consensus No. 7: Placenta Accreta Spectrum. Obstetrics & Gynecology. 2018;132(6):e259-e275. doi:10.1097/AOG.0000000000002983

5. Cahill AG, Beigi R, Heine RP, Silver RM, Wax JR. Placenta Accreta Spectrum. American Journal of Obstetrics and Gynecology. 2018;219(6):B2-B16. doi:10.1016/j.ajog.2018.09.042

6. Bujold E, Jastrow N, Simoneau J, Brunet S, Gauthier RJ. Prediction of complete uterine rupture by sonographic evaluation of the lower uterine segment. American Journal of Obstetrics and Gynecology. 2009;201(3):320.e1-320.e6. doi:10.1016/j.ajog.2009.06.014

7. Swift BE, Shah PS, Farine D. Sonographic lower uterine segment thickness after prior cesarean section to predict uterine rupture: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2019;98(7):830-841. doi:10.1111/aogs.13585

8. Cui X, Wu S. Ultrasonic assessment has high sensitivity for pregnant women with previous cesarean section occurring uterine dehiscence and rupture: A STARD-compliant article. Medicine. 2020;99(31):e21448. doi:10.1097/MD.0000000000021448

9. Zhu Z, Li H, Zhang J. Uterine dehiscence in pregnant with previous caesarean delivery. Annals of Medicine. 2021;53(1):1266-1270. doi:10.1080/07853890.2021.1959049

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Free Fluid in Morison’s Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic Pregnancy

Background

Vaginal bleeding and abdominal pain are common presenting symptoms to the emergency department (ED) in women in early pregnancy. While the majority of pregnant patients presenting with these symptoms are stable, a small subset of this group represents a ruptured ectopic pregnancy with a potential to rapidly decompensate, resulting in high rates of morbidity and mortality. Therefore it is critical for this diagnosis to be identified both accurately and rapidly.

The Focused Assessment of Sonography in Trauma (FAST) exam has been well studied in the acute trauma setting to identify internal bleeding however there is not much data on its use in the non trauma setting. In theory, it makes intuitive sense that it should perform similarly and be able to accurately identify significant non traumatic pelvic and intraperitoneal bleeding.

In a previous study, emergency physician (EP) performed bedside ultrasound (US) in suspected ectopic pregnancy was found to  decrease the time to both diagnosis and treatment [1]. The following study seeks to prospectively investigate the significance of positive fluid in Morison's pouch during transabdominal US examination performed by EPs in patients with suspected ectopic pregnancy. 

Free Fluid in Morison’s Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic Pregnancy‌

Clinical Question

Is EP performed US with identification of free fluid in Morison's pouch predictive of the need for operative intervention in suspected ectopic pregnancy?

Methods & Study Design

  • Design
    • Prospective observational study
  • Population
    • Conducted at Yale-New Haven Hospital, an urban Level 1 trauma center and teaching hospital
    • Pregnant women presenting to the ED in whom there was a suspicion of an ectopic pregnancy
  • Inclusion criteria
    • Female patients with positive pregnancy test who presented in first trimester with abdominal pain and/or vaginal bleeding and requiring further imaging or consultation
  • Exclusion criteria
    • No specific criteria
  • Intervention
    • EP performed transabdominal and transpelvic US evaluation for:
      • Free fluid in Morison's pouch (positive, negative or indeterminate)
      • Presence of intrauterine pregnancy (IUP), or no definitive IUP
      • Free fluid in the cul-de-sac (present, absent)
  • Outcomes
    • Follow up and chart review was performed by independent study investigators, blinded to ED US results, ultimately classifying the final outcome as ectopic or non ectopic pregnancy and further defining the management as operative or medical.

Results

Patient Flow Diagram 

Ultrasound Findings and Clinical Characteristics  of Patients

 

 

Strengths & Limitations

  • Strengths
    • Performed in ED based population
    • All ultrasound examinations performed by ED physicians making this applicable to point-of-care ultrasound
  • Limitations
    • Potential selection bias given that rate of ectopic pregnancy in study population was higher than most published rates
    • Not truly observational study as treating physicians were not blinded to ED US results
    • Some patients lost to follow up

Authors Conclusion

"Free intraperitoneal fluid found in Morison’s pouch in patients with suspected ectopic pregnancy may be rapidly identified at the bedside by an EP-performed US and predicts the need for operative intervention. Transabdominal pelvic US may show an IUP in more than one third of patients with suspected ectopic pregnancy."

Our Conclusion

While this paper does not have the methodological prowess of a multicenter randomized control trial, it accurately answers an important question with respect to positive fluid in Morison's pouch on ED US and the need for operative intervention in ectopic pregnancy. This study also highlights the niche of point-of-care ultrasound and why it is so critical to our practice as emergency medicine providers. Unlike radiological studies, which require increased time and may be difficult to obtain in critical patients, point-of-care ultrasound allows rapid identification of key findings that allow for early diagnosis and decision making.

Based on this study, the addition of positive fluid seen in Morison's pouch during ED US for suspected ectopic pregnancy now adds on a strong predictor for the need for operative intervention. This is especially important in unstable and hypotensive patients.

However, there are several caveats to understand when interpreting this data. First, all the patients in this study were enrolled after having a positive pregnancy test, therefore, prior to assuming that a young female with free fluid in her abdomen is from a ruptured ectopic pregnancy, a pregnancy must first be confirmed.  Second, not all free fluid in Morison's pouch in a pregnant woman is due to an ectopic pregnancy. In this data set, there was one patient that had a definitive IUP and free fluid in Morison's pouch which was found to be from a ruptured corpus luteal cyst. There are also case reports of splenic artery aneurysm rupture in pregnancy that could mimic a ruptured ectopic [2]. If an IUP is identified on transabdominal ultrasound, unless the patient is receiving advanced reproductive techniques, alternative explanations for the free fluid should at least be considered before a heterotopic pregnancy is presumed. Third, while this study demonstrates excellent specificity of positive fluid in Morison's pouch and the need for operative intervention in suspected ectopic pregnancy, it has very poor sensitivity. Therefore, ED US should be used as a rule in technique and does not replace formal ultrasound and obstetrical consultation if the diagnosis is not clear.

The Bottom Line

Free fluid found in Morison’s pouch in patients with suspected ectopic pregnancy can be rapidly identified at the bedside by emergency providers and predicts the need for operative intervention.

 

Authors

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Rodgerson JD, Heegaard WG, Plummer D, Hicks J, Clinton J, Sterner S. Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med. 2001; 8:331–6.
    2. Lynch MJ, Woodford NW. Rupture of a splenic artery aneurysm during pregnancy with maternal and foetal death: a case report. Med Sci Law. 2008;48:(4)342-5.

    3. Moore C et al. Free fluid in Morison's pouch on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy. Acad Emerg Med. 2007; 8: 755-8

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Prospective Outcomes of Pregnant ED Patients with Documented Fetal Cardiac Activity on Ultrasound

Background

Vaginal bleeding is a common cause of presentation to the emergency department (ED), and is the leading cause of presentations to the ED among patients with first trimester pregnancy [1]. It is reported that up to 25% of pregnancies have some bleeding within the first trimester [2]. Based on previous data, bleeding in the first trimester represents an increased risk of spontaneous abortion (SAB), with up to 50% of women losing the pregnancy [3]. However, patients with first trimester bleeding and a documented intrauterine pregnancy (IUP)  with fetal heart tones (FHTs), represent a subset of first trimester bleeding patients with improved outcomes, with rates of SAB ranging from 11.1-16.4% [4-5]. These previous studies were performed in outpatient obstetrical clinics and no prospective data exists with respect to outcomes in this subset of patients presenting to the emergency department. 

Prospective Outcomes of Pregnant ED Patients with Documented Fetal Cardiac Activity on US

Clinical Question

What is the rate of SAB in pregnant women presenting to the ED with first trimester bleeding and a documented IUP with cardiac activity?

Methods & Study Design

  • Design
    • Prospective observational study
    • Convenience sample of pregnant patients presenting to the University of Utah ED from January 1, 2008 through April 30, 2010.
  • Population
    • Pregnant women presenting to the ED with abdominal pain and/or bleeding
  • Inclusion criteria
    • Ultrasound (performed by ED physician at bedside or formal radiology study) demonstrating an IUP with FHTs and whose pregnancy dates placed them in the first trimester (< 13 weeks)
  • Exclusion criteria
    • No specific criteria
  • Intervention
    • Ultrasound demonstrating IUP with FHTs
  • Outcomes
    • Rate of SAB at 30 days after ED visit
    • Patients were contacted by telephone at least 30 days after their ED visit and asked about the status of their pregnancy

Results

Strengths & Limitations

  • Strengths
    • Performed in ED based population
    • Majority of ultrasound examinations performed by ED physicians making this applicable to point-of-care ultrasound
  • Limitations
    • Performed at single academic center
    • Low patient enrollment leading to large CI for rate of SAB
    • 85.9% patient follow up rate
    • Patients only followed out to 30 days after ED visit

Authors Conclusion

"In this prospective study of ED patients with first trimester bleeding and/or pain, we found that patients who had an IUP and FHTs by ED US had a 14.8% rate of SAB at 30 days. These findings may help to better define risk of SAB after first-trimester bleeding and allow us to provide more accurate counseling and prognostic information to pregnant ED patients presenting with these symptoms.”

Our Conclusion

This is an excellent paper that helps provide emergency medicine providers with prognostic information  regarding women presenting to the ED during first trimester pregnancy with vaginal bleeding and a documented IUP with FHTs. Often in emergency medicine we are focused on ruling out the life threatening diagnoses, in the above scenario, ectopic pregnancy, and it can be easy to lose sight of other important aspects of patient care. This paper helps refocus our attention and gives us important data to be able to provide an already anxious patient with some useful information on the potential expected course of their pregnancy. With this data, we are now able to better define the risk of SAB after first trimester bleeding and provide improved counseling and prognostic information to these patients.

The Bottom Line

In ED patients with first trimester bleeding, those that have an IUP and FHTs by ED ultrasound have ~15% rate of SAB at 30 days. 

Authors

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Dighe M, Cuevas C, Moshiri M, Dubinsky T, Dogra VS. Sonography in first trimester bleeding. J Clin Ultrasound 2008;36(6):352-66.
    2. Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE. Patterns and predictors of vaginal bleeding in the first trimester of pregnancy. Ann Epidemiol 2010;20(7):524-31.
    3. Dideriksen KL, Lidegaard O, Langhoff-Roos J. First trimester vaginal bleeding and complications later in pregnancy. Obstet Gynecol 2010;115(5):935-44.
    4. Poulose T, Richardson R, Ewings P, Fox R. Probability of early pregnancy loss in women with vaginal bleeding and a singleton live fetus at ultrasound scan. J Obstet Gynaecol 2006;26(8):782-4.
    5. Siddiqi TA, Caligaris JT, Miodovnik M, Holroyde JC, Mimouni F.Rate of spontaneous abortion after first trimester sonographic demonstration of fetal cardiac activity. Am J Perinatol 1988;5(1):1-4.
    6. Mallin M, e. (2018). Prospective outcomes of pregnant ED patients with documented fetal cardiac activity on ultrasound. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 26 January 2018, from https://www.ncbi.nlm.nih.gov/pubmed/21334156

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